January 3rd, 2022
The Oregon Primary Care Association (OPCA) was founded in 1984 by a group of five or six Oregon safety net clinics and the Oregon Office of Health Policy. Many of the founding clinics had been established during the War on Poverty, some as volunteer-run clinics, others as non-profit clinics. They sought to bring a community-centered, community-driven approach to health care, a philosophy that ran counter to the physician-owned for-profit model prevalent in many parts of the state. Although nine health centers had been formed statewide by 1984, Oregon’s overall safety net health care infrastructure was fractured and uneven. Many communities could not easily access or afford to receive care.
The founding clinics believed a statewide membership organization could facilitate buildout of this critical system. Although many had yet to receive FQHC designation, they realized federal funding would be critical to ensuring and expanding access to primary care services. At the same time, clinics in other states were beginning to form statewide non-profit membership organizations, spurred in part by a 1980 grant NACHC received from the Robert Wood Johnson Foundation. Thus, motivated regular meetings began, and in 1984, the organization filed for non-profit status.
Colin Wood, OPCA’s Board Chair, spearheaded efforts to secure funding to hire staff for the new organization, and in 1986 OPCA won a federal grant for teen pregnancy prevention that largely focused on migrant seasonal farm workers. Northwest Regional Primary Care Association (NWRPCA), a non-profit membership organization serving FQHCs in Alaska, Idaho, Oregon, and Washington, served as the fiscal sponsor for the grant. OPCA contracted with Rebecca Landau, a nurse with a public health background, to serve as its first employee. Further expansion occurred in 1988, when Ian Timm joined OPCA as its first executive director.
Building Capacity, Removing Barriers
OPCA’s early capacity building efforts focused on two main areas: providing training and technical assistance to health center staff and assisting Oregon clinics in meeting the federal requirements to become an FQHC. All FQHCs must meet an array of federal requirements regarding care quality, service comprehensiveness, and ensuring access regardless of ability to pay. “If you’re going to provide care on a sliding fee basis that is based on a patient’s income, but you also want to stay in business so you can keep serving the community, that requires a careful balancing act,” said Timm.
Simultaneously, OPCA engaged in a wide range of policy and advocacy efforts to address roadblocks facing patients and health centers. When Oregon State Senate President John Kitzhaber initiated the Oregon Medicaid Priority Setting Project in 1988 to prioritize which services would be covered by Medicaid, with the ultimate goal of increasing access, OPCA recognized the process could be swayed by special interest groups. Yet, it could also provide an opportunity for policy makers to hear public support of population health and primary care services. OPCA advocated successfully for statewide public hearings to define the values that would guide prioritization. Then, the organization alerted health center directors, board members, and patients about the meetings. Community input was crucial for creating a prioritized list that emphasized prevention and patient education, ensuring that primary care and preventative approaches would play a central role in Oregon’s Medicaid program.
At times, the political and funding environment could be hostile. In the early 1990s, the state Medicaid agency began refusing to reimburse health centers for providing certain types of services, such as case management and interpretation, despite federal regulations specifying such services were reimbursable. OPCA tried unsuccessfully to resolve the issue with agency staff and leadership. In 1993, OPCA sued the agency in federal court. OPCA eventually won a negotiated settlement in 1994, and the state Medicaid agency agreed to recognize FQHC status and federal requirements regarding reimbursement of health center services.
Another challenge soon emerged, when Oregon’s Section 1115 federal Medicaid waiver was approved to move Medicaid members into managed care organizations. It became apparent no existing managed care organization wanted to provide care for health center patients in Oregon. Once again seeking to address infrastructure barriers, OPCA joined with Oregon Health and Sciences University (OHSU) and the Multnomah County Health Department to form CareOregon, the state’s only safety-net-founded Medicaid managed care organization. CareOregon continues today as a non-profit managed health care organization and is the largest managed care organization statewide.
“The period where we took the state Medicaid agency to court, and also made our own managed care organization, was a real turning point for OPCA,” said Timm. “I was confident we could pull those off, because of the dedication of our staff and all the people working in the community health centers.”
Advancing Innovations in Patient Care and Health Center Payment
OPCA’s second executive director, Craig Hostetler, transitioned into the role in 2003. Soon after, OPCA and health center staff visited Southcentral Foundation, a community health center in Alaska, which inspired a vision for a new level of care for Oregon’s CHCs: a team-based approach to working with patients as equal partners. Instead of doctors dictating treatment plans to patients, a team of health providers and staff collaborated to meet patients where they were. This new approach to care aligned well with the community-driven, community-centered philosophy of FQHCs, and OPCA began a series of initiatives to support health centers in adopting this approach.
Despite promising results for patients and staff, challenges quickly emerged. A team approach clashed with fee-for-service, where only certain kinds of providers (like doctors) could bill for services, and those providers had to see a certain minimum of patients each day to maintain the clinic’s financial solvency. All the coordination needed for successful teamwork would have to fit in at the edges, and providers would need to see even more patients to pull in the revenue to support extra staff. The two priorities were at odds with one another, rendering this new model of patient care unsustainable.
Thus, OPCA began a multi-year effort to partner with the state Medicaid agency toward reforming the payment model. Instead of being paid per patient seen, health centers would be provided a global budget. This system, known as capitation, would focus less on which staff worked with patients, and instead emphasize how well patients were cared for. “Capitation itself is not innovative,” notes Hostetler. “It provides flexibility to innovate.”
In 2013, OPCA launched the Advanced Care and Payment Model, an initiative that simultaneously moved clinics into a new payment model while providing substantial technical assistance and training supports to facilitate innovation, advancements, and peer learning. As of 2020, 20 clinics and two Rural Health Centers caring for over 196,000 patients across Oregon have opted into the program, and at least 21 states have implemented or initiated efforts toward catalyzing similar changes.
In 2018, Joan Watson-Patko joined OPCA as its third executive director.
In 2020, Oregon’s 34 community health centers (CHCs), including two Look-Alikes, served as vital state and federal partners in providing a more equitable comprehensive vaccination program by helping remove barriers for populations throughout Oregon that have been most severely impacted by COVID-19.
Oregon health centers mobilized as soon as vaccines were available, and have hosted 15 pop-up vaccine clinics, 20 mobile events, and 13 school-based events between January and July, among other vaccine programs offered at CHCs across the state. Oregon’s Federally Qualified Health Centers (FQHCs), also known as community health centers, deliver integrated medical, dental, and behavioral health services to communities that might not otherwise be able to see a provider at over 270 locations statewide.
“Health centers are trusted sources of quality community-based care and are uniquely positioned to assist in vaccinating vulnerable and hard-to-reach communities across the state, including people experiencing homelessness and poverty, Black, Indigenous, and People of Color (BIPOC), agricultural and migrant farm workers, and people living in rural and frontier communities,” said Watson-Patko. “Oregon’s community health centers have been critical in ensuring greater access and
equity in testing and vaccination to the communities most impacted by COVID-19.”
As of July 2021, Oregon’s health centers saw COVID-19 positivity rates for racial and ethnic minorities in Oregon at three times the state average of 5%. Health centers in Oregon are vaccinating people of color at similar or higher rates than their shares of the total population.
OPCA is a non-profit membership association of Oregon’s 34 Federally Qualified Health Centers (FQHCs), including two FQHC Look-Alikes, as of 2021. Oregon’s community health centers deliver integrated medical, dental, and behavioral health services to Oregon’s communities made vulnerable at over 270 locations statewide. Over 466,000 Oregonians receive their care at a community health center, including one in four people on the Oregon Health Plan, as of 2021. The organization is committed to achieving health equity for all by leading the transformation of primary care across Oregon. OPCA has played a vital role in establishing and fostering the state’s safety net primary care infrastructure. OPCA is a key player in the movement to ensure that all Oregonians can receive high quality, comprehensive health care, regardless of ability to pay.
Timeline of key events in OPCA history
1984: OPCA is founded by a group of clinics and the state Office of Health Policy
1986: Rebecca Landau joins OPCA as its first employee, where she runs a teen pregnancy prevention program
1988: OPCA hires its first executive director, Ian Timm
1991: the Oregon legislature publishes its prioritized list of health services to be covered by the Oregon Health Plan
1993: OPCA joins with Multnomah County and OHSU to create CareOregon, the state’s only safety net-founded Medicaid managed care organization
1994: OPCA wins a negotiated settlement in federal court against the state Medicaid agency to ensure appropriate reimbursement of FQHC services
2003: Craig Hostetler is named OPCA’s second executive director
2006-2013: OPCA undertakes a series of initiatives to facilitate transformation toward team-based approaches to providing care
2012: OPCA partners with Oregon Health Authority to develop and secure approval for an alternative payment methodology for FQHCs
2018: Joan Watson-Patko joined OPCA as its third executive director.